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What the U.S. Election Means for Rural America

Disclaimer: Physicians for Human Rights is a non-partisan organization that works at the intersection of medicine, science, and law to forensically document human rights abuses, build capacity in local communities, and advocate for justice around the world. All posts about United States or international elections reflect the views of the individual author and not the organization. For the past six weeks, I have been in rural South Carolina doing a family medicine rotation. This town is what one would often think of as a classic rural American town. The only restaurants are fast-food chains – Bojangles, Subway, McDonald’s. The phone signal is so weak that, unless I am connected to WiFi, my phone is useless. Folks who live here own a lot of land and love to go deer hunting. Others live in old houses with a lot of extended family and not enough food. Many people are part of Native American tribes and live in reservation communities. Most are on Medicare or Medicaid or have no insurance at all. What I find most surprising is that, regardless of everyone’s living situation and background, they all love President Trump. According to them, he is saving America. Every other person has told me that the COVID-19 pandemic is an organized plan by Democrats to overthrow the government. Chances are high that, when I ask patients if they want the flu shot, they look at me like I am crazy. “Honey, do you want to kill me? The flu shot is what gives people the flu. I never get that.” At first, I was self-conscious and uncomfortable in these surroundings. Even the doctors I work with are dedicated Trump supporters. Considering the president's criticisms of the scientific and medical communities throughout the pandemic, despite our sacrifices for the American public, the juxtaposition is difficult to square. If politics come up, the pro-Trump energy is often so intense that I choose to stay quiet. One patient, though, changed my mind and helped me better process their viewpoints. Like most of our patients, she brought a big bag overflowing with her medication bottles. Recently, she had heard the president talking about how China brought the coronavirus to America, and she decided that taking her medications, which come from China, was too dangerous. She had completely stopped all of them, and no matter what I said to try to convince her otherwise, she refused to believe that they are safe and helpful. There are so many reasons that people cannot take their medicines, but conspiracy theories from the president should not be one of them. Why is President Trump able to connect to this community so strongly? Why do these patients and colleagues believe him and no one else? They know that he would like to make cuts to Medicare and Medicaid, but they simultaneously believe he is the only person looking out for them. Native American patients have heard his comments about minority groups, yet they pray he will be re-elected. Most of them don’t look down on immigrants, or think that families should be separated, or believe that women shouldn’t have rights over their bodies. At the same time, most have grown up in communities where abortion ostracizes you, religion and Church community bring you a family, and immigrants only exist in the abstract on the news. I have learned that I cannot justify my shock about their beliefs by simply attributing it to ignorance or lack of education. Rather, their core beliefs are often in direct conflict with each other, and like all humans, they have complex, non-linear, and occasionally illogical thoughts to process these conflicting beliefs. This election is sure to unravel more conflicting thoughts from people across the political spectrum. Take the chance to listen. Continue to work towards the things that you are passionate about. But in the process, we cannot lose our ability to connect with each other. Suffering and cruelty go beyond one president or one election. Problems in our society point to our failure as a country to work together over decades and generations. Regardless of what happens during this election and over the next four years, we cannot let one person take away our collective, intrinsic ability to do good. Veena Mehta is a third-year medical student at the Medical University of South Carolina and serves as the Regional Chapter Mentor for the PHR SAB's South and South Atlantic regions.

Nightmare on Peach Street: The Horrendous State of Georgia's Detention Centers

Located less than 10 miles outside the heart of Atlanta lies Clarkston, Georgia, a city celebrated for its ethnic diversity. Clarkston has been referred to as the “Ellis Island of the South,” and the “most diverse square mile in America.” It is a celebrated and welcoming reminder of progress. Yet, Clarkston lies in close proximity to some of the country’s most horrific immigration detention centers. Perhaps a reflection of the United States itself, the state of Georgia is home to a wide spectrum of beliefs, behaviors, and level of respect for human rights. There exists a tension between Georgia's two histories: one of deeply rooted racism and oppressive policies and one of the civil rights movement forged by Dr. Martin Luther King Jr. that inspired change. The latter continues today by activists like John Lewis and Stacey Abrams. While “Black Lives Matter” and “Hate Has No Place Here” signs line the streets of metro Atlanta, the region serves as just one piece of a largely divided puzzle and is far from indicative of the attitudes of Georgians as a whole. It is within this complex landscape that we see the conditions of the Georgia detention centers intersecting not only with politics, but also economics, and, importantly, health care. Follow the money and see where it goes... Sprinkled throughout the state are six immigration detention facilities: Stewart Detention Center, North Georgia Detention Center (NGDC), Irwin County Detention Center, Folkston ICE Processing Center, Robert A. Deyton Detention Facility, and Atlanta City Detention Center (ACDC). By comparison, there are seven immigration detention centers in the entire state of California, which is not only more than 2.5 times larger than Georgia, but also shares a border with Mexico. The Stewart, Irwin County, Folkston, Deyton, and North Georgia detention centers are run by private companies and remain fully operational today. Stewart Detention Center is the second largest male and trans-women detention center in the U.S. With 1,725 beds, it receives more transfers of individuals detained than almost any other facility and even some states. Called the “black hole of America's immigration system,” Stewart is located in Lumpkin, GA, a rural town located an hour outside of Atlanta with a population of 2,741, according to the 2010 census. By simple calculations, at full capacity, individuals detained at Stewart make up about 63% of Lumpkin’s population. Sadly, reporting after the 2010 census by Facing South found that immigrants were held in detention centers to be counted for the census before being deported out of the country. In 2012, Stewart County received 85 cents per inmate per day, which contributed to more than half of the county’s entire annual budget. Meanwhile, across the state, reporting in 2017 from the Atlanta Journal-Constitution showed that construction of the Folkston ICE Processing Center costs Georgian taxpayers $73.79 daily per bed, amounting to $116.7 million in expenses over the next five years. From a purely economic standpoint, the U.S. (already more than $23 trillion in debt) and, particularly, residents of Georgia cannot afford this expense. From a human rights perspective, we cannot afford to ignore these violations. Health care, even if detained, is a human right What the Georgia detention centers lack in fiscal responsibility, they make up for in immorality and indecency. A 2012 ACLU report on Georgia detention centers identifies a range of human rights violations at Stewart, Irwin, and ACDC, including, but not limited to, insufficient personal hygiene supplies, poor nutrition, and limited food options. In 2011, Stewart ran out of toothpaste and soap and had just three working showers for 58 individuals. The report is filled with accounts of sporadic and rushed mealtimes leaving many hungry and woefully malnutritioned. Meals at these facilities almost never contain any fruit and only rarely include green vegetables or protein. Many individuals detained lost large amounts of weight while in detention, including Grzegorz Kowalec, who lost an astonishing 68 pounds over the course of a year. According to Freedom for Immigrants, the top complaint filed from individuals in immigration detention centers was medical neglect and abuse. In September 2011, the assistant warden at Stewart admitted that the medical unit had had no physician on staff since August 2011, and a follow up in December of that year revealed that one had still not been hired. In addition, the ACLU of Georgia was informed by ICE that Stewart had been without a physician since August 2009, a period of almost two and half years, which is significantly longer than the standard previously set by the private owner of the detention center, Corrections Corporation of America. Furthermore, individuals in ICE facilities reported that requests for medical care were severely delayed and, in some cases, ignored completely. Angela Kelley was detained at Irwin and resorted to a six-day hunger strike in order to see a nurse after filing multiple requests for over a month to see a medical professional. Even when medical staff are available, it is rare that they speak the language of the individual or have an interpreter present for the encounter. On occasion, the medical neglect far exceeds limited access to medical care and constitutes medical abuse: "I feel like I'm going crazy....When I get upset, they just give me more medicine. I can't tell them I'm really upset or they just put me in a helmet and handcuffs for a few days. That's torture! I don't see anybody. I don't really care about anything. I just want to get out and get into a program that will help me." - Ermis Calderone, former detainee at Stewart Detention Center “The first six months I took the [HIV] medicine in Nigeria it didn’t work, but for the past three years with treatment my viral load was undetectable and my CD4 count was healthy. I spent one week here without medicine. In the second week, the lab drew blood and said my CD4 had dropped to 400 and my viral load was up. In the third week, the doctor asked questions about my medical history. In the fourth week, the lab did another blood test, but they didn’t answer anything I asked them, and I still had no medicine...A lot of people here are very sick and they still won’t take them to the hospital...I’m scared of what can happen to me...I’ve seen people die.” - Robert, former detainee at Atlanta City Detention Center. This kind of abuse and neglect resulted in 178 reported deaths in immigration centers between 2003 and 2018, three of which occurred in Georgia detention centers in 2018 alone. In more recent times, two detainees have died of COVID-19 while in ICE custody in Georgia as of March 2020, with alarming reports of failure to comply with any meaningful COVID-19 mandates. In September 2020, a whistleblower reported involuntary hysterectomies of women detained in Irwin County Detention Center. The shocking report of alleged forced sterilization follows a long history of unsafe, irresponsible, and abusive health care. We are quantitatively able to measure the death toll at the detention centers; however, we must also remember the rates of human suffering and long-term mental and physical health outcomes that former detainees must live with are just as important. These individuals are not just statistics - they are our neighbors, our patients, and our peers. It’s not all bad news! Well, maybe it is… Even so-called “wins” within the Georgia immigration landscape present their own challenges. In 2018, the city of Atlanta broke its contract with ICE, and the last individual detained was removed from ACDC. In 2019, Atlanta Mayor Keisha Bottom, signed historic legislation to re-purpose the ACDC site located in the heart of Atlanta. The Equity Center will replace the former state-run immigration detention center with the mission of “advancing racial and economic equity, promoting restorative justice, and investing in the well-being of individuals, families, and communities.” While the city taking a stand by removing its affiliation with a maligned ICE facility was a well-intentioned success (you can read more about human rights violations at ACDC in this Project South report), the word choice is important here: the individuals once at ACDC were removed, not released. Likely, they were removed to another detention center - one that is privately run, with potentially worse conditions, and farther from family, urban areas, and media hubs. Additionally, many detainees rely on nonprofits and organizations that can provide pro-bono resources to help them navigate the immigration landscape in Georgia. Unsurprisingly, the majority of these resources are located in and around metro Atlanta - far from the rural detention centers where they were likely moved it. So what? Although it is often medical neglect and abuse in the Georgia detention centers that remain at the forefront of our minds as healthcare providers, it is clear that the inhumane treatment does not stop at medical neglect. There is very little, if anything, about the centers that could be called “acceptable”, including the very fact that in this country we subject people to forced detention under the guise of preventing illegal immigration. The very nature of these facilities is criminal. While some may argue that the state of Georgia’s detention centers is solely an issue for politicians or lawyers to combat and that we, as healthcare providers, should “stay in our lane,” the terrible conditions and consequent negative health outcomes faced by those in detention are a violation of medical rights and, thus, human rights. As medical students and physicians, we are advocates, and the human beings in these detention centers are our patients—this is our lane. Nicole Lue is a second-year medical student at Emory University School of Medicine.

Mental Health Afflictions of Children in the Middle East

Amidst the COVID-19 pandemic and protests worldwide against racial injustice, one thing has not changed: the fact that armed conflict and instability continues to hang like an unrelenting cloud over the Middle East. This has had an impact not only on infrastructure, physical health, and survival, but also on the mental health of those who are fortunate enough to survive (or unfortunate to have to live through) the unending war and conflict, and resulting devastation. Armed conflicts have a devastating impact on the mental health of affected populations. Post‐traumatic stress disorder (PTSD) and depression are the most common mental disorders in the aftermath of war for both adults and children, occurring in at least one third of people directly exposed to traumatic war experiences. PTSD among Syrian refugee children has been so severe and unprecedented in magnitude, that it has escalated to the point where some mental health professionals have coined a new term for these particular cases of trauma: “human devastation syndrome”. Dr. M.K. Hamza, a Syrian neuropsychologist, uses this term as it aptly reflects the fact that the children’s devastation “is above and beyond what even soldiers are able to see in the war”, including “seeing dismantled human beings that used to be their parents, or their siblings”. In the Gaza Strip, 7 out of every 10 of evaluated adolescents have been found to meet the criteria for post-traumatic stress disorder (PTSD), with nearly 97.5% of these same adolescents displaying severe anxiety levels. A 2007 survey of Palestinian schoolchildren found that 80% of children witnessed shootings firsthand, with 10% exhibiting a depressive-like state, and 14.1% exhibiting emotional difficulties. Psychiatric patient admittances in Gaza have increased by 69% within the last two years, with increases in reported anxiety, depression, and suicidal thoughts and behaviors. A 2018 Save the Children survey in Iraq found that “43 per cent of children in the city of Mosul reported feeling grief always or a lot of the time” (Save the Children, 2018). Despite the widespread nature of anxiety, depression, and PTSD, much of the responsibility for remedying these emotional and psychological impacts has fallen to non-governmental organisations such as Medecins Sans Frontieres (MSF- Doctors without Borders), which has provided welfare and support to many Iraqis with mental health ailments. MSF advises that there are currently only four psychiatrists for every 1 million residents in Iraq, and even fewer professionals are trained in related mental health professions such as psychological counseling. As things stand, there are only four professionals currently looking after Syrian refugees in Iraq who must grapple with carrying out 70-100 counseling sessions per week with these individuals. Similarly, in Jordan, a country now hosting nearly 700,000 refugees, there are a total of 31 psychiatrists for the whole country, which is largely composed of refugees from Palestine, Iraq, and Syria. Lebanon and Turkey also have inordinate numbers of Syrian refugees who have fled the devastation within their own country. Unfortunately, most psychiatric professionals are strictly hospital-based and provide mainly biological care leaving no mental health professionals to address PTSD in these populations.

Add to that the situation in Yemen, home to the worst humanitarian crisis on earth, where hundreds of thousands have been killed, with millions suffering from malnutrition and preventable diseases such as cholera. It has been difficult to quantify and evaluate mental health there, but it is clear that the situation is especially dire. When you have children witnessing the deaths of their family members, or witnessing their loved ones withering away from starvation in front of their own eyes, it takes a massive psychological toll. Moreover, there has been a shortage of psychiatric specialists in Yemen since the start of the Saudi intervention. In January 2016, the WHO estimated that there were 40 psychiatric specialists in Yemen, most of whom were based in the capital, Sana’a. In December 2016, the director of the mental health program at the Ministry of Health suggested there were just 36 psychiatric specialists. Mental health is not integrated into the primary health care system, and many Yemenis are unable to access treatment when they first make contact with the healthcare system. Mental health in the COVID-19 Era On top of the devastation and mental health crisis, these populations have had to contend with the COVID-19 pandemic as well. In their dire state, to have to grapple with this condition only adds to the mental health catastrophe that they face. Since the pandemic and national lockdowns, the United Nations High Commissioner for Refugees (UNHCR) has documented alarming reports of increasing mental health issues among the many refugees in the Middle East and Northern Africa. In Lebanon, Libya, Yemen, and other countries in the Middle East, there have been spikes in suicide, domestic violence, insomnia, and depression.

To the credit of the UNHCR, they have been implementing a number of approaches to address these mental health issues. They are utilizing and training personnel in Psychological First Aid (PFA), an evidence-based approach to intervene for individuals in the immediate aftermath of disaster and terrorism to prevent the development of PTSD. For instance, in Iraqi refugee camps, trained community workers have provided PFA to primary healthcare staff, NGO workers, and community outreach volunteers. Furthermore, the UNHCR has created hotlines to receive and respond to psychological issues.

This is helping the situation, but more needs to be done to address the dearth of mental health professionals, as well as the root cause of the dire circumstances that have led to the resultant mental health catastrophe in the first place.

The cruel fact of the matter is that U.S. and Western foreign policy and intervention have played a big part in why the situation is what it is today. To quote award-winning Beirut-based journalist Robert Fisk of The Independent, “We always arrive with our tanks and our helicopters and our [armored] personnel carriers, and our soldiers, instead of arriving with our teachers, our educators, our doctors and our social carers.” From my position, I would like to emphasize doctors, and add on professionals from all spheres of health care, including mental health.

We must acknowledge the role of our country in perpetuating the catastrophe in that part of the world today. I can think of no better way than those in health care and mental health can get involved than through joining human rights organizations and offering their services to this part of the world. Moreover, we need to put pressure on our elected leaders to change their stance and approach on the Middle East of endless military intervention. We need our leaders to take a non-interventionist policy, ending our military occupation and interference with the affairs of other sovereign nations. All this has done is create a never-ending cycle of destruction and failed states.

Among other things, the current U.S. administration is openly supporting the Saudi-led intervention in Yemen which is creating the worst humanitarian catastrophe and resultant mental health crisis in the world. The U.S. has cut all funding to the United Nations Relief and Works Agency (UNRWA), the main organization sustaining the lives of Palestinian refugees in Gaza. These decisions are only going to make the situation and ensuing mental health catastrophe even worse. We need to make our voices heard, and to show not only solidarity, but also directly intervene and offer our services to address the needs of these people. It is the very least we, as Americans and Westerners, can do. Millions of lives depend on it. Racheed Mani is a third-year medical student at the Renaissance School of Medicine at Stony Brook University. He is also the founder of the PHR student chapter at his medical school.

The United States' Youth Detention System Poses Serious Threats to Health Care

There are over 43,00 youth currently held in juvenile detention and correctional facilities across the United States. Long before the COVID-19 crisis, the conditions of confinement in these facilities threatened the wellness and proper development of incarcerated youth. Today, with COVID-19 wreaking havoc on our country and the world, that threat has grown exponentially. Our communities have failed to adequately protect some of our most vulnerable youth, but we cannot continue to fall short. Typical conditions of juvenile detention and correctional facilities include, but are not limited to, inadequate access to proper educational and developmental programs, physical and emotional abuse, claustrophobic and unsanitary spaces, limited contact with family/support systems, and lack of adequate healthcare resources. Research has shown that these conditions lead to adverse physical, emotional, and mental health outcomes. During a pandemic, such adverse conditions are only exacerbated. Research by public health experts shows that incarcerated populations are among the most vulnerable during pandemics. Prisons and detention centers often act as epicenters for highly contagious viruses like COVID-19 due to extremely confined living quarters and unsanitary conditions. Behind bars, youth are not able to participate in proactive measures to keep themselves safe, such as social distancing, frequent hand washing, accessing personal protective equipment, or staying in sanitized spaces. Further, youth detention and correctional facilities are often unequipped to meet the medical needs of youth if an outbreak should occur. Lack of resources allotted for prison health, as well as various security policies, increase the likelihood for delays in both diagnosis and treatment of the disease. Once diagnosed, youth are unlikely to have the capacity to properly isolate themselves from other youth. Further, higher rates of chronic health conditions in incarcerated youth have the potential to lead to more serious complications of the virus. If staff become ill, it will be difficult to provide care and support to youth, and if lockdowns are utilized, they will only exacerbate the spread of the virus. In addition to the physical health threats this pandemic poses on incarcerated youth, there is a growing concern about mental and psychiatric stressors. We know there is an increased prevalence of adverse childhood experiences (ACE) among youth who are incarcerated. Outbreaks of the virus in detention facilities threaten to lead to further ACEs and exacerbate the effects of previous traumas. For example, many facilities are currently prohibiting visitations from family, legal representatives, and other community members, as well as canceling school and other regular programming, leading to further isolation and lack of social support. In several facilities, there are reports of children being locked in their rooms for more than 23 hours a day as a form of “isolation” to mitigate the spread of COVID-19, not much different from solitary confinement. Aside from the trauma of being isolated for this long, these actions may in turn lead to increased self-harm and suicidal ideation. Such circumstances jeopardize both short-term and long-term health outcomes for these youths. In such dire conditions, what can be done to help keep incarcerated youth safe? The medical community must join the fight to protect incarcerated youth alongside human rights organizations and family members. We can do this by urging our local government and boards of health to tackle the issue in a variety of ways including: Release youth who can be safely cared for in their home communities. Create transition plans for youth released from custody that ensure their basic needs are met. Within the constraints of public safety, reduce new admissions to juvenile detention & correctional facilities and increase the use of diversion strategies. Develop and publish COVID-19 response plans and ensure data regarding suspected and confirmed cases are publicly available. Ensure all staff members are trained on the implementation of the response plans. Ensure that youth and families are notified of suspected and confirmed cases in a timely manner. Ensure that appropriate access to medical and mental health prevention, treatment, and care is the norm. Provide emergency funding to expand community-based services and supports for youth diverted to or released from detention facilities. The COVID-19 pandemic is only highlighting problems that are deeply ingrained in the juvenile justice system. Highlighting and advocating for solutions during this time can lead to more long-term change. As healthcare professionals and medical students, we have an obligation to help prevent the injustices and adverse health outcomes of youth in the juvenile justice system. This issue is not new. Injustices have always existed, but there has never been a more urgent time to act than now. Chris Diaz is a fourth-year medical student at The Ohio State College of Medicine. If you would like to get more involved in the #FreeOurYouth initiative, you may contact him at Sources: Akiyama MJ, et al. "Flattening the Curve for Incarcerated Populations - Covid-19 and Jails and Prisons." New England Journal of Medicine. NEJMp2005687 Cullen K and Ndudom E. "Doctors Call for Releasing Youth from Secure Custody During COVID-19 Crisis." Juvenile Justice Information Exchange. Kinner SA, et al. "Prisons and custodial settings are part of a comprehensive response to COVID-19." The Lancet. Teplin LA, et al. "HIV and AIDS Risk Behaviors in Juvenile Detainees: Implications for Public Health Policy." American Journal of Public Health 93, no. 6 (June 2003): 906–12,; Committee on Adolescence, “Health Care for Youth in the Juvenile Justice System.” Fatos Kaba, et al. "Solitary Confinement and Risk of Self-Harm Among Jail Inmates." American Journal of Public Health 104, no. 3 (March 2014): 442–47, 10.2105/AJPH.2013.301742 Logan-Green P, et al. "Childhood Adversity among Court-Involved Youth: Heterogeneous Needs for Prevention and Treatment." 5 J. Juv. Justice 68 (2016). Yael Cannon & Dr. Andrew Hsi. "Disrupting the Path from Childhood Trauma to Juvenile Justice: An Upstream Health and Justice Approach." 43 Fordham Urb. L. J. 425 (2016). American Academy of Pediatrics. "Responding to the Needs of Youth Involved With the Justice System During the COVID-19 Pandemic."

Don't Separate Migrant Children from their Parents

As a medical trainee who works with children and families, I am encouraged by the order to release children who have been held for more than 20 days in the detention centers run by Immigration and Customs Enforcement (ICE) by July 17, as issued by Judge Dolly M. Gee of the United States District Court for the Central District of California. This order is critical in light of the insufficient measures put in place in detention centers to ensure that children and families are protected against COVID-19. Not only are families in these centers unable to practice the evidence-based social distancing that states and federal government agencies have promoted throughout this pandemic, but they also often lack access to masks, hand washing supplies, and cleaning supplies - basic necessities that are critical in the face of an unprecedented viral pandemic. While the decision by Judge Gee stating that ICE must work to release the children with “all deliberate speed” is a step in the right direction, either along with their parents or to suitable guardians with the consent of their parents, dire concerns remain that children may be separated from their parents in facilitating this release. Such a policy would ignore the overwhelming evidence of harm from detention and from separating children from their parents, which has been articulated by multiple American medical societies, including the American Academy of Pediatrics, which represents the voice of pediatricians across the U.S. Family separation can cause irreparable harm to children and is an act from which many families may never convalesce. As our government leaders are undoubtedly aware, multiple courts have ruled the practice unconstitutional. As medical trainees, we are obligated to safeguard the rights of children and share our concern regarding the safe release of children with their families. Releasing children is a positive step, but separating parents from children to facilitate this release will likely cause children and their families irreparable harm, not unlike the Zero Tolerance Policy that separated thousands of children from their parents. I have had the privilege of treating immigrants and asylum seekers and have witnessed firsthand the serious detriment that the threat of detention poses to the health and well-being of children. I have also had the honor of working alongside immigrant physicians who have stood by their neighbors to provide care to families across the U.S. during the COVID-19 pandemic. While I advocate for all children in this crisis, I recognize that refugee children are disproportionately at risk. In light of these recent events, I implore the leaders of the Department of Homeland Security and ICE to release children responsibly with their parents or to a suitable guardian in conjunction with the June 26, 2020 ruling by Judge Dolly M. Gee. Children should be released from ICE detention with their parents immediately. Families belong together. Rebecca Leff is a medical student at Ben Gurion University in Beer Sheva, Israel. She serves on the Physicians for Human Rights National Student Advisory Board’s Advocacy Committee. Please use this letter as a template by which to send a letter of your own to DHS and ICE leadership.

The Imprisonment of Pregnant Women under COVID-19

Andrea Circle Bear, an inmate imprisoned on account of drug charges, passed away after giving birth on Tuesday, April 28th while on a ventilator in federal custody in Texas. Her case sparked controversy worldwide in the discussion of reproductive justice and access to health services. As future physicians, the health care considerations of incarcerated individuals are vital to building stronger public health measures for all populations. When incarcerated women, especially those who are pregnant, are taken into custody, there are concerns about the emotional, physical, and mental wellbeing of themselves and their unborn child, urging for reform regarding care of the vulnerable prisoner. With both the mother’s and child’s lives in question, amending health care and prison legislation in the midst of COVID-19 is of utmost importance. New guidelines that protect the health and safety of pregnant women charged under federal law and ensure proper health standards in prisons to minimize contact with other inmates have become an emergency. As defenders of human rights, physicians and trainees hold a collective responsibility to advocate for the protection of these women. Speaking for those who lack a voice and for human rights to be upheld is every physician’s duty. In light of the COVID-19 pandemic, there is an increased need to reduce the prison population and protect incarcerated individuals, as viruses and diseases are easily spread within prisons. Although it is impossible to anticipate and prepare for every possible health threat posed to prisoners, Circle Bear’s arrest for a non-violent drug charge highlights the urgency of the current moment to protect vulnerable prisoners - especially non-violent offenders - as she was simultaneously pregnant and infected with SARS-CoV-2. Her prison’s conditions, rather than protecting prisoners by enforcing stricter social distancing measures and releasing smaller groups for exercise, recreation, and meals, unfortunately failed to meet the public health guidelines established by the Centers for Disease Control and Prevention (CDC), which contributed to widespread transmission within the prison. It is disturbing that, in the midst of a global health crisis, the United States federal prison system failed to protect its prisoners by releasing those charged with non-violent crimes or to ground them under house arrest. Pregnant prisoners are especially vulnerable, as they have limited access to timely adequate medical care and are often subject to abuse and mistreatment, inadequate diets lacking fruits and vegetables, and the placement of shackles that limit their mobility. Pregnant women have compared themselves to confined animals while being transported to and from their doctor’s appointments, fearing that they may trip or fall on their stomach and harm the child they are carrying. Circle Bear is not the only case of incarceration of a pregnant woman with COVID-19. In India, Safoora Zargar is currently behind bars due to her involvement in protests against a controversial citizenship law (the Citizenship Amendment Act of 2019), which gives refuge and citizenship only to non-Muslim immigrants from neighboring countries. The bill is discriminatory against Muslims, portraying them as infiltrators who have entered the country illegally. Safoora has been charged as a conspirator due to her association with the Jamia Coordination Committee (JCC) for inciting hatred and violence, attempted murder, and promoting enemity between different religious groups, even though these charges are largely unfounded. Upon arrest, her right and access to health care were compromised, as she was accused under the Unlawful Activities Prevention Act (UAPA), which makes it impossible for her to post bail. Furthermore, due to COVID-19 restrictions, she has been denied visitations by her husband and lawyer. Police who arrested her and sent her to an overcrowded prison during the pandemic failed to concern themselves with her unique circumstances. To date, she remains in an overcrowded prison with inadequate health precautions in place to protect her from disease. In light of these cases, we must consider alternative methods to safeguard the health of pregnant incarcerated individuals. Methods of home confinement for prisoners charged with non-violent crimes are necessary if we are to stop the spread of the virus. The benefits are clear: home confinement restructures incarceration, adheres to social distancing regulations, is cost-effective, and reduces the burden on overcrowded prisons. In particular, such measures benefit pregnant women as they are given comfort, safety, and access to health professionals from the enclosures of their own homes. With a tracking system in place to locate these women, authorities may also rest assured that the health and wellbeing of their prisoners is upheld while permitting them to serve for their transgressions. Additionally, for pregnant prisoners who may not be released, we as physicians and trainees must ensure that women have access to proper nutrition and that facilities set up proper hygiene protocols, including widespread personal protective equipment for both prisoners and prison employees. Prisons must make clear the rights entitled to pregnant women, must prohibit shackling during transportation, and must improve living conditions within their facilities to prevent institutional ignominy of these patients. For pregnant prisoners, there are two lives at stake, and their health rights must be especially protected in light of a deadly pandemic. More efforts are needed to reevaluate and reform the health care provided to incarcerated populations in light of COVID-19. As the cases of Circle Bear and Zarfar have taught us, pregnant women demand special attention and protections under these circumstances. As medical professionals and trainees, we are in a unique position to give voice to such patients and demand that higher quality care is afforded them through this pandemic. Leah Sarah Peer is a medical student at Saint James School of Medicine and a graduate of Concordia University, Specialization in Biology, Minor in Human Rights in Montreal, Quebec, Canada.

COVID-19 in Gaza: The Need to Lift the Blockade

As the world continues to battle the COVID-19 pandemic and cases and fatalities rise daily, these times call for essential geopolitical solidarity among even the most bitter of enemies. The United Nations has called for the suspension of all sanctions against the likes of Sudan, Venezuela, and Iran, countries for whom sanctions have dealt a severe blow to infrastructure, including in health care. One place that is ill-equipped to combat a pandemic, where the health system has been teetering on the edge for over a decade, is the besieged Gaza Strip, where a Gazan woman was recently confirmed as the first death in the region from the virus. Gaza, under the rule of the Islamic militant group Hamas since 2006, has been under a blockade imposed by Israel and Egypt for nearly 13 years. This period has been marred by deadly conflict between Israel and Hamas, in which thousands of Palestinians have been killed, buildings and facilities destroyed, and the allowance of essential medical supplies and food severely limited to the bare minimum needed for survival. 97% of the water in the Gaza Strip is unfit for human consumption, and electricity is severely limited to a few hours per day. While one cannot ignore the attacks and incendiary rhetoric of this intractable conflict, we must not lose sight of the fact that 70% of the nearly 2 million people in Gaza are refugees; half of the population are children. Gaza is also one of the most densely populated places on earth. The squalid conditions in its refugee camps, combined with its under-equipped hospitals and medical facilities, mean that a COVID-19 outbreak could be devastating. Its dense population means that “social distancing” is practically impossible. At the moment, there are only 2,500 beds and 87 ventilators available in Gaza. As highlighted by Palestinian-Canadian physician Dr. Tarek Loubani, many of these units are either already in use or woefully insufficient. It cannot manage the nightmare scenario of thousands of Gazans contracting the virus. Moreover, Israeli defense minister Naftali Bennett has recently halted COVID-19 testing in Gaza. Another issue here is the fact that Gaza’s limited access to electricity has meant that most hospitals are heavily dependent on generators. More importantly, much of the Gazan population already suffers from various medical conditions in part due to injuries sustained in the conflict, inadequate nutrition and contamination, and cancers for which access to treatment is extremely limited. The immunocompromised state of so many Gazans renders them even more susceptible to the lethality of the virus. We write this simply as a call to stress the dire health crisis that exists in Gaza, one that is sadly, in large part, manmade, manifesting from the blockade of the besieged enclave and devastation imparted by war.

Why is this issue relevant to us here in the United States? Well, the U.S. is the principal financial supporter of Israel and has thereby perpetuated the blockade of Gaza. It has provided billions of dollars of military assistance to Israel and vetoed virtually all U.N. resolutions holding Israel accountable for the blockade, thus enabling it to act with impunity in Gaza. Moreover, the recent decisions of the Trump administration to cut all funding to The UN Relief and Works Agency (UNRWA), a major provider of essential humanitarian and medical aid, has contributed further to the deterioration of the humanitarian crisis in Gaza. According to the International Committee of the Red Cross, the healthcare system in Gaza would likely not be able to cope with more than 100 to 150 serious COVID-19 cases at any one time. The situation is further compounded by the fact that, due to the blockade, many local medical professionals have left Gaza over the years in pursuit of opportunities elsewhere, meaning that medical manpower is also an issue. Furthermore, the Trump administration’s decision to cut all funding to UNRWA has meant that the cash-strapped organization has not been able to effectively carry out preventative health measures, such as sanitizing the refugee camps in the region. The World Health Organization (WHO) has indicated that Israel, while having allowed certain pharmaceuticals to enter Gaza, has either delayed or prevented the import of medical equipment, consumables, and spare parts. The Palestinian Authority (PA) also bears culpability here, as it has worsened this shortage of medical supplies over the years by cutting the transfer of medicine into Gaza in order to thwart its political rivals in Hamas.

While Hamas has imposed lockdown measures and quarantined individuals who have tested positive or have been in contact with those testing positive, these measures are not enough to avoid the nightmare scenario that could occur. The most vital action is that of Israel and Egypt to lift their blockade on Gaza and allow desperately needed medical equipment and supplies to enter the besieged enclave. The U.S. must act as a partner in these efforts to ensure that Israel and Egypt lift the blockade in these extraordinary circumstances. In 2018, the U.N. reiterated that the blockade “amounts to the collective punishment of the two million residents of Gaza, which is strictly prohibited under the Fourth Geneva Convention.” Israel needs to ensure that Palestinians in Gaza who contract COVID-19 can receive the appropriate care that is currently unavailable in the impoverished region. To the credit of various activist groups, such as the NGO Physicians for Human Rights (PHR) – Israel, there have been calls within Israel for its health ministry to provide assistance to medical authorities in Gaza, making it clear that, in light of the ongoing health crisis, Israel is responsible, by international law, to provide the requisite means of health care and treatment to the Health Ministry in Gaza. Moreover, Gazan medics have recently received training from their Israeli counterparts in Ashkelon, indicating some degree of cooperation between Israel and Hamas in quelling the virus.

However, the best means of preventing an absolute health catastrophe is to lift the blockade immediately. Security threats are often mentioned as the rationale behind the blockade, but permitting the passage of fundamental medical supplies would benefit all parties in the region. Palestinians, Egyptians, and Israelis, who live in such close geographical proximity to one another, would all benefit from such measures to prevent the epidemic from spreading from one community to the next in the blink of an eye. So far, there are over 50 confirmed cases in the Gaza Strip. The nightmare scenario has not yet been realized, but Gaza, now with a recent uptick in cases, is teetering on the precipice. This virus does not discriminate between Arabs and Jews, and the lifting of the blockade would provide a critical lifeline to individuals both within and around the Gaza Strip. Millions of lives depend on it. The Stony Brook PHR chapter is a collection of medical students based at the Renaissance School of Medicine at Stony Brook University on Long Island, NY.

'Maximum Pressure' Sanctions Threaten Patients' Right to Health

Economic sanctions are commercial and financial penalties used by countries to restrict trade or transactions with specific entities of foreign nations. They can vary widely, from targeting specific individuals or institutions to targeting entire sectors of a nation’s economy. Governments often impose economic sanctions as a foreign policy tool to alter the behavior of states that threaten their interests, violate human rights, or are deemed to be a security threat. The United States has imposed more economic sanctions on other nations than any other country in the world, presently targeting Cuba, Iran, Sudan, North Korea, Syria, and Venezuela. Economic Sanctions Hurt Ordinary People - Not Just Governments A growing body of research shows that economic sanctions can have dire consequences for ordinary people, contributing to an increase in preventable disease and deaths. Although broad economic sanctions are typically presented as targeting governments, they often undermine a nation’s entire economy, and ordinary citizens pay the greatest price. Economic sanctions restrict the targeted nation’s ability to trade or access international markets, which causes a dramatic reduction in the nation’s income, thereby leaving public and private sectors with less capital to finance basic necessities. With a contracting economy, citizens face increased unemployment and decreased purchasing power, subsequently limiting their ability to buy essential foods and medicines. To mitigate their impact on ordinary civilians, sanctions often include exemptions to allow for the trade of humanitarian necessities, such as life-saving medicines and medical equipment. However, these exemptions have proven to be ineffective in many countries due to the global dominance of the U.S. financial system and the threat of secondary sanctions. Because international banks and corporations are often tied to the U.S. financial system, U.S. sanctions often prevent other financial and commercial actors from trading with the targeted nation, even in the goods that are nominally exempted. Furthermore, international actors are discouraged from initiating trade with sanctioned countries due to the fear of having secondary sanctions placed on them by the U.S. The U.S.’s history of prosecuting companies that sell medical supplies to sanctioned countries only exacerbates this issue. Patients Pay the Price - From Venezuela, to North Korea, to Iran In Venezuela, broad economic sanctions that the Trump administration implemented in 2017 have inflicted serious harm to human life and health. They have exacerbated Venezuela’s economic crisis by causing the production of oil to fall by 60 percent, leading to a disruption in crucial social services. According to a report by the Center for Economic and Policy Research, these sanctions have contributed to reducing the Venezuelan public’s caloric intake, an estimated 40,000 deaths in 2017-2018, and the displacement of millions of Venezuelans. Meanwhile, North Korea experienced sanction-related delays and funding shortfalls for specific UN humanitarian programs after U.S. economic sanctions were intensified in 2016. These delays affected programs that address severe acute malnutrition and vitamin A deficiency and are estimated to have led to nearly 4,000 deaths in 2018 alone, primarily in children under the age of five. A UN Panel of Experts expressed particular concern for an extensive list of humanitarian-sensitive items that are presently sanctioned in North Korea, including medical appliances such as an ultrasound, cardiograph, artificial respirator, X-ray machine, and orthopedic appliances for persons with disabilities. In Iran, over two years of 'maximum pressure' sanctions have contributed to soaring unemployment, a plummeting currency, and immense inflation. The price of basic foods, such as bread and milk, have significantly increased in the wake of these sanctions. Due to both the threat of secondary sanctions limiting the import of specialized medicines and restrictions on raw materials needed to produce medical goods, access to medicine and medical supplies has sharply declined. In fact, U.S. pharmaceutical exports decreased from $26 million per year under Obama-era sanctions to only $8.6 million under the Trump administration. Doctors and patients have reported critical shortages of medications, ranging from antiepileptics to chemotherapies. A recent Human Rights Watch report has also underscored several cases in which crucial medicines listed on the humanitarian exemption list have been prevented from entering Iran due to sanctions. The International Court of Justice has ruled these humanitarian exemptions to be insufficient. Economic Sanctions and Human Rights Although economic sanctions are recognized by international law as a legal strategy to maintain international peace and security, current evidence shows that these recent 'maximum pressure’ sanctions have violated the human rights of citizens in multiple countries. Per General Comment Number 14 of the UN Committee on Economic, Social and Cultural Rights, "Parties should refrain at all times from imposing embargoes or similar measures restricting the supply of another state with adequate medicines and medical equipment, [and] . . . restrictions on such goods should never be used as an instrument of political and economic pressure." In reference to current U.S. unilateral sanctions on Cuba, Venezuela and Iran, the late UN special rapporteur Idriss Jazairy stated, "The resort by a major power of its dominant position in the international financial arena against its own allies to cause economic hardship to the economy of sovereign States is contrary to international law, and inevitably undermines the human rights of their citizens." We entered medicine to treat patients, not to bear witness to their harm. At times, it may be challenging to tease out the extent to which patient harm inside sanctioned countries is caused by 'maximum pressure' sanctions versus other international and domestic factors at play. However, when sanctions fail to include reliable and accessible humanitarian channels that protect patients, they violate international law and threaten the core tenets of our profession - first, to do no harm. As physicians-in-training, we believe that opposing sanctions that infringe on patients’ right to health is our professional and moral obligation. Laila Fozouni is a medical student at the University of California San Francisco, and a recent graduate of the Harvard School of Public Health. Parsa Erfani (@ErfaniParsa) is a medical student at Harvard Medical School.

Immigrants Are at Particular Risk of COVID-19. Here's What Congress Can Do.

Physicians, residents, and medical students around the country are seeking signatures for Congress to take action for immigrants in light of COVID-19. There are two specific issues brought on by the current public health crisis: the health risk of detainees in immigrant detention centers, and the need for undocumented immigrants to have access to COVID-19 testing, treatment, public health information, and relief benefits. It is of utmost importance that Congress takes on these issues to ensure immigrants have equitable protection from COVID-19 and appropriate access to health care. Releasing Immigrants in Detention Centers Immigrants, refugees, migrants, and asylum seekers in detention centers need to be released and safely incorporated into communities in order to ensure immigrant and greater community safety and to secure the greatest public health benefit as our nation fights the current pandemic. Detention centers place the detainees at an increased risk of communicable diseases, including COVID-19. Even under normal circumstances, immigrant detention centers find it difficult to prevent viral outbreaks of mumps, chickenpox, and influenza. Influenza virus, in particlar, has a lower viral replication number (R0) than COVID-19. Recent Lancet, New England Journal of Medicine, and Health Affairs articles cite the inability to remain distanced in enclosed spaces, limited access to healthcare services, and frequent turnover of people as ideal conditions for COVID-19 to thrive and decrease the effectiveness of mitigation strategies at large. Within the past few weeks, ICE has reported 90 confirmed COVID-19 cases among its detainees and more than 20 cases among its employees. These totals may be lower than the actual number of cases in these facilities for many reasons, including the ongoing lack of testing capacity in the United States. Internationally, a German refugee camp experienced a 3,486% increase in cases over five days due, in part, to conditions similar to those in U.S. detention centers. Not taking appropriate actions to reduce the number of detainees in immigrant detention centers endangers the lives of employees, detainees, and the broader community. While the American Civil Liberties Union (ACLU), physicians, and other groups have been effective in advocating for the release of nearly 700 detainees, over 30,000 people still remain in ICE detention centers. These efforts have included public statements, letters to Congress, and many immigrants and advocacy groups filing lawsuits asking for their release. Additionally, the delayed response by ICE has led to the development of the Federal Immigrant Release for Safety and Security Together (FIRST) Act, which was just unveiled last week by Senator Cory Booker. Considering most individuals in immigrant detention centers have never been charged with a criminal offense, it is in the public's health interest for those without violent offenses to be released or placed in Alternative to Detention (ATD) Programs, which are cheaper than current detention programs and have demonstrated high compliance. Ensuring Access to Care for Undocumented Immigrants It is critical to highlight the effects that this pandemic is having on our country’s undocumented immigrants. Immigration advocacy groups such as the Migration Policy Institute, the Centers for American Progress, and the ACLU have recently raised concerns that many vulnerable groups such as DACA recipients, undocumented immigrants, and certain lawful permanent residents do not have equal access to provisions for COVID-19 testing and treatment within the Coronavirus Aid, Relief and Economic Security (CARES) Act and Families First Coronavirus Response Act (FFCRA). The expansion of care provided by the current legislation failed to include provisions for immigrants or remove certain health care eligibility restrictions on immigrants. For example, many immigrants rely on emergency Medicaid in order to qualify for access to care in many states, and this provision was not expanded in Congress's initial response packages. Additionally, current immigration policies, namely the public charge rule, have the potential to negatively impact both individual immigrants and family units’ willingness to access care due to fear that this assistance will be counted against their ability to apply for legal permanent resident status in the future. The barriers that remain in place despite the unique circumstances during COVID-19 make access to necessary care far more difficult, if not impossible, for these populations. H.R. 6437 (Coronavirus Immigrant Families Protection Act) was introduced earlier this month to ameliorate the shortcomings of the earlier legislation in regard to immigrant families and ensure their protection from COVID-19. The additional provisions of this legislation, along with the suspension of the public charge rule, are critical for every person in our country to have the necessary resources to make it through this crisis. We need legislation that remedies the inadequate care provided to undocumented immigrants in light of COVID-19, as this care is integral to overcoming this pandemic as a nation. Legislation Needed It is vital that our country begins to address the health concerns for immigrants, refugees, migrants, and asylum seekers during this current pandemic, which can be addressed by the following actions: Legislation that seeks to release detainees from detention centers and improve the medical conditions for those that must remain in detention (like the FIRST Act) Legislation that will provide the necessary resources that undocumented immigrants in the U.S. need in order to remain healthy during the current pandemic As current and future medical professionals, we have the power to raise concerns about this vulnerable population and improve our country’s public health by advocating for Congress to speak on behalf of these immigrants, refugees, migrants, and asylum seekers. Tristan Mackey is a medical student at the University of South Carolina - Greensville School of Medicine. Thomas Pak is a medical student and PhD candidate at the University of Iowa Carver College of Medicine. Acknowledgements: Dayna Isaacs, Sally Midani, Titus Hou, Huan Khong, Daniel Park, Daniel Lee, David Long, Zoe Moyer, Haritha Pavuluri, Keanan McGonigle, Drayton Harvery, Rohan Khazanchi, Pooja Patel, Claire Justin References:

Assessing Medical Students’ Understanding and Knowledge of Crisis Pregnancy Centers

What Are Crisis Pregnancy Centers? Pregnancy Counseling Centers, also referred to as crisis pregnancy centers (CPC) or pregnancy resource centers, are non-medical entities whose aim is to dissuade women from seeking legal abortion to terminate pregnancy. They are intentionally advertised as comprehensive medical facilities with licensed clinical professionals. However, they only offer limited, select services and provide misinformation regarding abortion and contraception to prevent women from pursuing these options. The Search for Information If a person were to do a Google search of Crisis Pregnancy Centers, one of the first suggested searches is as follows: “What do pregnancy centers offer?” The automated answer provides quotes from “Fact Sheet: Pregnancy Health Centers,” which states that these centers “provide support services, medical care, and resources to women…” In reality, these centers are non-medical entities, which directly contradicts the misinformation provided by the search engine. Furthermore, this information is inherently biased. Among the top search engine hits is an article by the Charlotte Lozier Institute, a pro-life political activist group that aims to “reduce and ultimately end abortion...” The misinformation regarding pregnancy centers begins as early as an initial inquiry on an internet search engine. The Issue CPCs frequently mislead individuals seeking reproductive care and avoid disclosing their financial, political, or religious associations to patients and the public. Moreover, these centers often receive state and federal funding without complying to medical standards of care. According to Heartbeat’s Worldwide Directory of Pregnancy Help, there are 4116 pregnancy centers in the US, and, as of 2017, there are only 808 abortion centers. Lack of Awareness Despite the prevalence of CPCs, the general public that may seek care from these centers is often unaware of their deceptive practices. A survey done in 2020 of medical students who are members of the American Medical Association (AMA), an organization focused on healthcare policy/advocacy, showed that only 21.8% of medical students are aware of CPCs and have a comprehensive understanding of their practices, while 14.5% have no understanding at all about CPCs. Almost half of surveyed students, 47.3%, answered that they have some knowledge about CPCs. However, the content and source of their knowledge is unknown, and it is unclear whether their knowledge includes fact-based information about CPCs or includes only their exposure to false advertisements by CPCs. Considering medical students, especially those who have self-selected to be active within a healthcare advocacy organization such as the AMA, are arguably more aware than the general public of issues related to access to care, there is legitimate concern that the general public is being misled regarding practices at CPCs. Those seeking care at CPCs may not realize that they are being misinformed about their health options. Figure 1. Awareness and understanding among medical students of Crisis Pregnancy Center practices (Source: American Medical Association, 2020). Conclusion The survey results highlight medical students’ lack of awareness and understanding of CPCs. CPCs lack transparency regarding their limited scope of services and their anti-contraception and anti-abortion missions. This lack of transparency results in a violation of medical ethics that can be construed as coercive. The current practices of CPCs constitute a public health emergency and pose danger to women seeking comprehensive and evidence-based reproductive healthcare in this country. While CPCs are certainly allowed their free speech and opinion on the matter of abortion, their intentional misinformation campaigns, misleading advertisements, and interference in medical care presents a concern to medical ethics and patient rights. This is an issue that deserves more scrutinizing press, less state and federal funding, and more public awareness and education. Authors: Neha Siddiqui, Carle Illinois College of Medicine; Sarah Swiezy, Indiana University School of Medicine; Pavithra Wickramage, UNT Health Science Center - Texas College of Osteopathic Medicine; Carly Polcyn, University of Toledo College of Medicine and Life Sciences; Candise Johnson, University of Mississippi Medical Center; Leah Genn, Florida State University College of Medicine; Pooja Nair, University of Missouri-Columbia School of Medicine References: Family Research Council. A passion to serve: How pregnancy resource centers empower women, help families, and strengthen communities. 2nd ed. Published 2010. Accessed August 25, 2019 Bryant AG, Levi EE. Abortion Misinformation from Crisis Pregnancy Centers in North Carolina. Contraception. 2012;86(6):752-756. doi:10.1016/j.contraception. 2012.06.001. Swartzendruber A, Steiner RJ, Newton-Levinson A. Contraceptive Information on Pregnancy Resource Center Websites: A Statewide Content Analysis. Contraception. 2018;98(2):158-162. doi:10.1016/j.contraception.2018.04.002. Covert B, Israel J. “The states that siphon welfare money to stop abortion.” ThinkProgress, 3 Oct. 2016, Waxman, Henry A. False and Misleading Health Information Provided by Federally Funded Pregnancy Resource Centers: Prepared for Rep. Henry A. Waxman; United States House of Representatives, Committee on Government Reform - Minority Staff, Special Investigations Division. United States House of Representatives, 2006. “Fact Sheet: Pregnancy Help Centers-- Serving Women and Saving Lives” Charlotte Lozier Institute. January 17, 2018. “About Us” Charlotte Lozier Institute. 2020. Data Center. Guttmacher Institute. 2020. Worldwide Directory of Pregnancy Help. Heartbeat International Affiliates. 2020. Rosen J.D. The public health risks of crisis pregnancy centers Perspect Sex Reprod Health. 2012; 44: 201-205 Crisis Pregnancy Centers in the U.S.: Lack of Adherence to Medical and Ethical Practice Standards. Journal of Adolescent Health. 2019, 65:6:821-824.

Close the Camps in the Time of COVID-19

There are over 200 ICE detention facilities across the United States, where detainees often spend months to years awaiting their decisions on immigration cases. As the COVID-19 pandemic spreads across the United States, health professionals have warned that the disease could prove deadly in these facilities, where conditions are subpar in the best of circumstances. Recent reports show that in both adult and pediatric facilities, migrants in detention are routinely denied care and treated like criminals. Routine chronic health maintenance is neglected, medications are scarce, and acute concerns are brushed aside. Many facilities operate without in-house physician staff, relying instead on under-trained and overworked nurses whose duties extend far beyond triage. In a pandemic, these already existent weaknesses will be amplified, leaving detained migrants vulnerable to significant risk of contracting COVID-19 under conditions in which quality care is all but impossible. ICE has come under scrutiny repeatedly for the poor quality of their migrant detention centers. Their centers are defined by cramped quarters and overcrowding, lack of basic hygiene and medical supplies, and inhumane treatment of migrants. Because of the dismal sanitation conditions in these centers, they have already seen widespread outbreaks of infectious diseases like mumps, measles, influenza, and chickenpox. Such diseases can be reliably prevented with adequate vaccination and screening regimens. However, given the poor treatment of and resources allotted to migrants, it is questionable whether detention centers can effectively contain the spread of preventable infectious diseases. This is complicated by COVID-19, for which we currently do not have an effective vaccine, treatment regimen, or screening protocol. COVID-19 spreads through respiratory droplets, and scientists have already advocated for frequent hand washing, social distancing, and isolation as ways to mitigate disease spread and severity. Given the crowded conditions and inaccessibility to adequate hygiene in migrant detention, it would be impossible for its inhabitants to partake in these practices. Detainees have already protested these conditions with fears of spread of the virus. Many are participating in hunger strikes, and at least one has committed suicide. Even though ICE has increased its supply of N95 respirator masks to limit transmission of the disease, it is unclear how efficacious this will be given the poor baseline condition of centers. Additionally, given the shortage of personal protective equipment (PPE) throughout hospitals in America, these valuable resources would be best allocated for healthcare workers directly helping afflicted patients who need them the most. Migrants are imprisoned for reasons drastically different to those incarcerated for committing crimes. However, cited conditions - including overcrowding and poor sanitation - are common between jails, prisons, and migrant detention centers. Prisoners cannot adequately practice “social distancing,” and fears of outbreaks of COVID-19 in jails and prisons have stimulated policy makers to order the release of hundreds of low-risk prisoners in order to combat overcrowding, create more quarantine spaces, and mitigate disease spread. Such a model should be extended to ICE detention centers, in which most detainees are also non-violent and solely being held for immigration purposes. By March 27, US District Judge Analisa Torres had already ordered the release of individuals in ICE custody with underlying medical conditions that predispose them to infection, and we must consider widespread releases as the epidemic continues to ravage communities throughout the U.S. In light of COVID-19, we must re-evaluate what these detention centers mean for our communities as the virus spreads and question how we value human life. The inhumane and under equipped conditions of detention centers pose not only a public health threat, but a major violation to foundational human rights. This crisis highlights the deep inequities faced by migrants and asylum seekers worldwide. As medical students who serve asylum clinics in Philadelphia, New York, and Boston; as advocates on the Physicians for Human Rights Student Advisory Board; and as ourselves children of immigrants, we have witnessed how systems currently in place reinforce the structural violence that keeps the powerless disempowered. As the COVID-19 pandemic continues, it is imperative that we value the lives of those who lack voice and agency. How our nation chooses to respond reflects the importance we place on securing the health and human rights of even the most vulnerable. Healthcare and public health professionals, immigrant advocates, and community members will join the national call-in to representatives, senators, and local ICE directors on Tuesday, March 31 as part of the National #FreeThemAll Week of Action. Open letters and petitions are already circulating in order to halt immigration enforcement and detention that places thousands of lives at risk. We are undoubtedly in a crisis, but that is all the more reason that we must stand up for the rights, care, and dignity of migrants in our country, for the betterment of all of our patients and communities. Michael Dorritie, Michelle Munyikwa, PhD, Shefali Sood, and Samantha Truong are medical students at Touro College of Osteopathic Medicine, University of Pennsylvania Perelman School of Medicine, New York University Grossman School of Medicine, and Harvard Medical School. They form the Physicians for Human Rights National Student Advisory Board’s Advocacy Committee.

Gun Violence Requires Medical Intervention

109. This is the number of people who died each day from firearms in the U.S. in 2017, the most recent year for which the CDC has published data . It is a staggering number, one that deeply damages the fabric of communities and tears families apart. What’s perhaps most disconcerting is that this number – 109 – may not come as a shock. It didn’t to me at first. We have become so numb to the perpetual violence that these weapons cause that 109 daily deaths no longer alarm us. But put that number in context – in the U.K., 126 people died in the entire year of 2015 due to firearms. Here in the U.S., we have nearly that many people dying each day for the same reason. We ought to acknowledge there is more we can do. Gun violence impacts all communities – from urban Chicago, to suburban Parkland, to rural Montana. Roughly 6 in 10 firearm deaths occur due to suicide, affecting predominantly white rural populations. The remaining 4 in 10 are homicides that affect predominantly black and Latino urban populations.This is clearly not an isolated issue, and it demands the national attention it deserves so we can achieve better outcomes for our families, friends, and patients in all walks of life. So, how can we begin to solve it? For one, we – as a medical community – must lead this fight and tell the stories of our patients. There is perhaps no institution more well positioned to lead the charge against gun violence than the medical field. When an individual is shot, they come to doctors and nurses – not the gun lobby – for help. We entered this field to promote the well-being of our patients, and it would be irresponsible to ignore the public health crisis we have on our hands. We must speak up and share our experiences to reduce the harm that we see daily due to firearms. As part of this charge, the medical community must further the middling research that’s currently available. Until just two months ago, firearm research had not received government funding in over 20 years, due in no small part to the Dickey Amendment. The gun lobby pushed the Dickey Amendment as a response to a thoroughly peer-reviewed study from 1993, which revealed gun ownership as a major risk factor for homicide and suicide in the home. In the nearly three decades since, over 600,000 individuals have died from gun violence in the U.S. Fortunately, Congress recently approved $25 million in firearms research for the CDC and NIH. It is a small but undoubtedly important first step in the march towards developing evidence-based approaches to gun safety. However, this crisis demands far more research funding than it currently receives, and healthcare organizations are uniquely positioned to tackle such a problem. Recently, Northwell Health launched a call-to-action for the 25 largest healthcare organizations in the U.S. to each pledge $1 million to fund gun safety research. With the weight of their world-class reputations, monetary support, and renowned research arms, these institutions should and can accomplish significant research to help guide our communities and public officials in promoting the safest gun practices. While these healthcare organizations have expressed interest in pledging to such a cause, most have not yet put their money where their mouths are. For those who work for such organizations, we must demand action from our leadership and implore them to lead the charge in combating gun violence. Additionally, we must educate our patients and their families about the safety measures available to them. For instance, many states have now passed Extreme Risk Protection Order (ERPO) laws , otherwise known as “red flag laws.” These laws temporarily suspend individuals’ access to firearms if they are deemed to be a present danger to themselves or others. While family members or police typically file such reports, physicians often find themselves at the intersection of gun violence and mental health. Alarmingly, suicide rates and gun-related deaths are up 33% since 1999. Therefore, it is our duty to make patients and their families aware of the mental health options they have and educate them that ERPO laws exist for their protection. Such laws are not meant to permanently restrict one’s gun ownership rights. Instead, they help patients and providers weather the current storm presented by gun access and acute mental illness, emotional distress, or drug use to improve outcomes in the long term. Early data already suggests that these laws have helped to reduce suicide and homicide rates among gun owners. Finally, we must advocate for reasonable gun safety legislation. The language is crucial here – gun safety is not the same as gun control. Regardless of individual interpretations and opinions of the Second Amendment, it has been thoroughly litigated and is not likely to change soon. Instead, we must focus our efforts on ensuring the highest level of safety for everyone in our country, while also preserving the right of responsible gun owners to own firearms. When automobile-related deaths rose in the 1960s and 1970s, we didn’t eliminate cars. Instead, we gathered robust research to redesign cars, redesign roads, and redesign how people are trained to drive. Automobile-related fatalities have plummeted since. In fact, in 2017, firearm-related deaths exceeded automobile-related deaths for the first time ever. The same approach is essential to reduce gun violence in our country. We must redefine our relationship with guns and the purposes they serve in our communities. Mandatory and robust background checks, bans on semiautomatic weapons, and restrictions on gun ammunition purchases are important starting points that we must champion to secure safer communities and better outcomes for our patients. Today, on the two-year anniversary of the Parkland shooting, physicians, nurses, medical students, and other healthcare professionals are called to lead the way in achieving better outcomes for our patients. We have the narrative evidence, the financial leverage, the research prowess, the legislative influence, and the compassionate hearts needed to elicit real change in the face of this public health crisis. Gun safety is a crisis that impacts all our lives, and today more than ever, it requires the medical intervention that it deserves. Michael Dorritie is a medical student in New York City. All views expressed are of the author and do not represent the views of his respective institutions.

© 2020 PHR Student Advisory Board

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